9314 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON - PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESB S. / (/ s / A I j 9314
'(,L.•//'/Cry vnW./ �/"/L! BUILDING —ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
.� NAM `C/ QTY. ELECTRIC PERMIT FEE
9d "111.1NE
CONTRACTOR'S
NAME 90 UTLETS-SWITCHES-PIECED 40-.eWI.00 y
-LIC.N0.3 /93v/pL LIGHTING FIXTURES 16:98/1.00 —
CONTRACTOR'S
3 JAPPLIANCES-RESIDENTIAL 4.00
f{O (.✓ PHONES 2 7— Q IPANELS ,10.00 r -- DATE OF APPLICATION
onCHITECT PANELS(OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
SS
ZIP EMP.METER OR POLE INS. —20.00
APPLICANT s
ADDRESSMOTORS SEE FEE SCH. — l. t "` - -
ADDRESS
SERVICE CHANGE 20.00 �T -7
0 0 o LICENSED CONTRACTORS DECLARATION TEMP.POLE P
le v v I herebyaffirm that 1 am licensed under provisions of Chapter 9
Q s, w p s ISSUANCE GATE
h Q w (commencing with Section 7000)of Division 3 of the Business and / U I BLDG. ELECT. PLG. MECH.
D z Professions Code,a my license is in full for " d i t j I �{ l
z o m License Class Lic.Number_ ..f71
La
O -o bat. Contraaor_r��C. LD
I r J n
a w a OWNER-BUILDER DECLARATION I bit of Cup ,tiro BUILDING PERMIT
o A U r INFORMATION
X3:
; w m I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
Fad Nj Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 4ao0 VALUATION
Code:Any city or county which requires a permit m construct,altar,
QQ ¢ Improve,demolish,Or repair any structure,prior to Its issuance,also ELEC.CONTR. LIC.NO. ELEC. (
a w0 Q requires the applicant for such permit to file a signed statement that TOTAJ
m he is licensed pursuant to the provisions of the Contractor's License L` PERMIT TO
FZQ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe < �r P4-867
� �a.y
i 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE I V
taro the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant loa civil penalty
of not more than five hundred dollars($500d.):
ALTER-DRAIN -WATER IEA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00
their sole compensation,will do the work,and the structure is no[ OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP ._5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments arc notintended or offered for sale.If,however,the building IGAS-EA.SYSTEM-1 1 NC.4 OUTLETS-6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00
builder will have the burden of proving that h¢did not build or it.- BUILDING USE
prove for purpose of salol. _ INDUSTRIAL WASTE INTER. 30.00 RES IND CON ve Dine,
O 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ 0 D
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.1 1.00
contracts for such projects with a contoctor(s)licensed'pursuant to pr
the Contract.,',License Law. SEWER-SANITARY-STO t_Aa260fot 1 TRACT NO. PARCEL NO.
❑ I am exempt made,Sec,_,B&RC.for this WATER HEATER W/VENT .}6.00 AL
reason
Owne` Date WATER SYSTEM ,
Ot CuPe fG ACC.DATE ACC.FILE NO.
WORKIiRS'COMPIiNSA'fION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certiBcaw of consent 10 self-insure,
or a certificate of Workers'Compensation_Insuranccee,or a certifiedcopy ZONING ENG.SITE NO.
PCIicyereoflSec.3800,Lab.CJ.uN,led 1aC171
Policy Nn. Company G
❑ Certil ieJ copy is hereby furnished.
Z O Cetlified IR
y s ed Ills the city inspection division. FE SPR I NK EN ERGY T 24
1-- d nnplicam Ley MISC.- REFER TO ORO. Y [3 N� Y [] N�
y CERf1 FICATF-OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 1&00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. W
1 0 (This section need not be completed if the permit is for one TOTAL O Y[:] N� Y❑ ry�
Z hundred dollar,IS 100)or less.)
U O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT„A,D FEE FEE SUMMARY
H mit is issued,I shall not employ any person in any manner so as to rr
O w become subject to the Workers'Compensation Laws of California.
D. Duce Applicant ALTER OR ADD TO MECH. BUILDING
}
03 NOTICE TO APPLICANT: If,after making this Certificate of E.- ,-,5, O n4
? emption,you should become subject to the Workers'Compensation APPLIANCE 15. 0 PLAN CHECK
provisions of Ilia Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 100 C.F.MFEE,) 4.0
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,44 . .) SEISMIC FEE
1 hereby affirm that there is a construction leading agency lix EXHAUST HOOD (WITH DUCT) 5.00
the perforniance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC ����
1 certify that I have read this application and state that III,above VENTILATION FAN (SINGLE) 4.00
. ordinances is Street. I agree to comply with all city and county BOILER-COMP PLUMBING 7Q
ordinances and stale laws relating to building construction, and (3 H.P.or 100,000 B.T.U.) 6.00
hereby enti authorize representatives ladies of this city to eine, upon the BOILER-COMP (Ove,100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless Ilia City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10,0 CONST.TAX
gmntrng of h�s ¢rmI MECH.CONT. LIC.NO. MECH.
TOTAL J`ry' TOTAL . .L
SI are o pp cunt/Contractor Date
OFFICE COPY